Thursday, July 24, 2008

Quality of Life in Italian Centenarians

These aren't true antecedents of longevity, but offer insight into perhaps which aspects of quality of life issues are most highly prevalent in centenarians vs. younger controls. That's about as good a correlation as other observational studies anyhow.

interest in centenarians has focused on two particular aspects: the antecedents of extreme old age and the psychophysical well-being of the very old. Our study deals with the latter aspect and aims to assess the quality of life of Italian centenarians.

Method:

using data collected using two questionnaires designed to investigate quality of life in elderly people, three groups of 38 elderly subjects were compared: centenarians and subjects aged between 75 and 85 years and 86 and 99 years.

Results:

the centenarians complained less spontaneously about their health (maintained in part by medical treatments), but declared having greater functional disability. Their cognitive function appears to be reasonably well preserved and they have lower scores for anxiety and depression than the subjects in the two younger groups. They consider themselves religious, satisfied with their financial situation but no longer interested in sex or involved in recreational activities. They report greater satisfaction with life and with social and family relations than do less elderly individuals.

Conclusions: the centenarians we interviewed seem to be well adapted to their lives and to maintain a more positive attitude than the subjects in the two younger groups.

Keywords: adaptation, centenarians, quality of life, religion, sex

Introduction

The number of Italian centenarians increased from 49 in 1921 to 1660 in 1990 [1]. Census data for 1993 are currently being processed but according to preliminarydata some 6000 centenarians were alive in Italy on 31 December 1993 [2]. Recently, several centres have joined the Italian Multicentre Study on Centenarians,which aims to assess the clinical and biological condition of centenarians. Preliminary results have highlighted a number of characteristics peculiar tocentenarians: they often have a family history of longevity, live in comfortable, family environments, have been hard workers and possess well-preservedpsychological and cognitive abilities. They are free from certain risk factors (such as hypertension, hypercholesterolaemia and symptomatic hyperglycaemia)and have always followed a balanced diet, based on natural foods. Their immune systems continue to function well and natural killer cells are particularlyactive [2, 3]-

International research into centenarians includes work on demographic and dietary characteristics, in addition to examining genetic/biological, neurologicaland neuropathological aspects of this age group and their life style and methods of coping [4-13]. Most research is therefore on the antecedents of extremelylong life [14] and psychophysical well-being in old age[15]. The aim of our study was to investigate the quality of life in centenarians in the Veneto region of Italy, based on the concept that long life should be examined not only quantitatively, but also in qualitative terms. At present we have access only to records from the townof Padua and some other places coming under local health unit ULSS 13 (S. Maria di Sala, Noale, Spinea, Scorze, Martellago, Mirano) but our research willbecome more widespread as we receive data from other local health units.

Materials and methods

The study was conducted between October 1992 and July 1995. Personal records were supplied by the data processing centre of the municipalities of Padua and Pordenone together with other record offices coming under local health unit ULSS 13. With the lists provided, 207 M. Dello Buono et al. we were able to gain access to the names of 57 people aged 100 years or more, 42 of •whom were resident in Padua, six in Pordenone and the remaining nine in the other municipalities of the health unit. Of the 42 residents in Padua who were able to participate in the study, the selected test package on the quality of life was only administered to 27 subjects: two refused to take part, two were too physically disabled, two had transferred to another municipality, one was not to be found at the indicated address and the remainingsubjects (seven women and one man) had died by the time of recruitment. Four of the six subjects from Pordenone were tested. Of the other two, one refused to take part while the other was too physically unfit to undertake the test. Only seven of the remaining nine residents from the other six municipalities were interviewed, as one was in poor physical health and the other could not be contacted. The totalnumber of subjects tested was therefore 38, including the 11 interviewed subjects who were not resident in Padua.

The questionnaires used were the Profile of Elderly Quality of life (PEQOL), which has been used in other studies [16, 17] and the LEIPAD quality of lifeassessment instrument developed to measure self-perceived functioning and well-being in elderly people [18]. (The three universities principally involved in the World Health Organisation European study that developed the LEIPAD instrument wereLeiden, Padua and Helsinki: the instrument's name is a combination of 'Leiden' and 'Padua'.)

The PEQOL questionnaire, which takes the form of a test battery, explores various dimensions of quality of life—physical health, cognitive capacities, psychologicalsymptoms, basic and instrumental activities of daily living (ADL and IADL), sleeping patterns, social support, religiousness and sexual relations—which form a 'profile' of the quality of life in elderly subjects(see Appendix 1). This questionnaire had previously been administered by means of door-to-door interviews to 462 subjects aged 75 years and older, chosen at random from the electoral rolls (1:10) of Padua andBrescia [16]. The instrument can be administered by non-specialized personnel after a brief training period and is relatively quick to administer (taking roughly 30min). The instrument has good psychometric properties, being partly based on scales which have been thoroughly validated.

The LEIPAD questionnaire provides additional self-reported information. Created with a view to studying quality of life in elderly patients in primary health care,it examines subjective views of physical and mental health, sexual relations, emotional status, level of self-esteem, expectations for the future, ADL, social andrecreational activities and financial situation. It also considers the cognitive status of the subject being tested in order to assess the reliability of the self-evaluation.

The instrument consists of 49 items, 31 of which can be grouped into seven 'core instrument scales'. Other items measure self-perceived personality disorders and social desirability, self-esteem, anger and faith in God. These 18 items can be grouped into a further five scales, referred to as 'moderator scales' (seeAppendix 2). Each item in the instrument assesses responses along a scale of 0 (best condition) to 3(worst condition). Some items of the 'moderator scales' have dichotomic answers so their score is 0 or 1. This paper reports the scores achieved on the core instrument scales and religiousness scale, since the other scales do not contain items comparable with PEQOL ones. The 38 centenarians tested to date were interviewed in their own homes or institution. From the group of elderly people tested in previous studies in Padua, 76 subjects were chosen by random stratification (one in every five, from an alphabetical list), 38 aged between 75 and 85 and 38 between 86 and 99- These constituted the control groups with which we compared our sample of centenarians. The sociodemographic characteristics of the centenarians andthe other two groups included in our study are reported in Table 1. The three groups were comparable with regard to gender and educational level. Of the 38 centenarians, 24 (19 women and five men) lived at home; the remaining 14 lived in institutions (13women and one man).

The statistical procedures used were Student's West, X2 analysis, ANOVA and ANCOVA variance and Table I. Socio-demographic characteristics of the subjects

Differences in mean years of schooling between the three groups: F = 0.92, P = not significant.

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Quality of life and longevity covariance analysis. The results were processed bymeans of SYSTAT statistical software [19].

Results

The package took longer to administer to the centenarians (the mean time taken was 44.0 ± 36.77 min, range 18-70, as opposed to 30± 21.21 min, range 15-30 in younger subjects) and was in no case self-administered, as the subjects frequentlyhad poor eyesight or their writing skills were not sufficient to allow them to fill in their answers.

Whenever it seemed advisable, relatives were asked to help by explaining the questions and generally creating a more relaxed atmosphere during testing.Description of the results has been divided into two main sections: the first assesses the data relating to self-sufficiency and the second to psychological well-being and cognitive performance.

Self-sufficiency

Table 2 presents the results obtained after administration of the IADL [20] and ADL [21] scales and those obtained from the PEQOL scale for physical status,comprising \6ad hoc items to investigate the presenceof pain, discomfort, functional disability (see Appendix1). Table 3 shows the results from the LELPAD physicalhealth scale.

Since the subjects aged between 75 and 85 years hadon average 1 year's schooling more than the other twoage groups, we decided to verify whether omitting thisvariable would modify the results. By using ANCOVAcovariance analysis we excluded the possibility of suchan effect for the variables considered. Variables whichwere not significantly different were also controlled forschooling; none of the results were significantlydifferent.

The centenarians reported a mean number of lostfunctions on the IADL scale exceeding the numbersreported by both the 86 - 99-year-old group and the 7 5 -85-year-old group. Comparison of adjusted values afterANCOVA did not modify these results. A similar resultwas obtained with the ADL scales, even after ANCOVAfor schooling. (Table 2).

On the IADL scales, 50% of the centenariansinterviewed (n = 19) reported eight lost functions,thus indicating that these subjects depend on othersfor basic daily living requisites such as shopping,money matters, use of medicines and the telephone.According to the results from the ADL scales on abilityto wash, dress and move about unaided and incontinence,only 18% (n = 7) were completely dependent.The centenarians and those in the 86-99-year-oldgroup spontaneously complained of an average of onlyone painful symptom compared with an average ofalmost two such symptoms in the youngest group.After allowing for educational level, the results do notchange (Table 2). The three groups did not, however,differ significantly in evoked painful symptoms. Thisapplied even after ANCOVA for schooling (Table 2). Onthe question on disability, the centenarians and elderlypeople from the intermediate age group had significantlyhigher scores than the younger subjects.

The centenarians' mean for spontaneously reportedlost function was not significantly different from thosereported by the subjects from the other two groups;after ANCOVA the result was similar (Table 2). Theintermediate age group reported a greater meannumber of lost functions evoked by the interviewercompared with the number reported by the centenariansand youngest age group; after ANCOVA forschooling the result did not change (Table 2).

Table 2. Mean points on the Profile of Elderly Quality of life scales scored by the three groups

The most impaired functions were hearing, eyesightand walking (especially in institutionalized subjects).Incontinence was also a common problem, as werecardiovascular disorders and decreased memory andcognitive performance. All subjects took at least onedrug and some took as many as 15 different types.As regards the LEIPAD questionnaire, comparativeanalysis of this aspect of the study—which alsoconfirmed the findings of the PEQOL—can beperformed for the scores obtained by the threegroups for the physical functions and self-care scales.In the former scale, the scores tend not to differsignificantly, whereas in the latter scale the threegroups differ significantly, with greater impairmentbeing reported especially by the centenarians (Table 3).

Psychological well-being and cognitive performance

Table 4 presents the scores obtained on the BriefSymptom Inventory [22] and on the Mini Mental StateExamination (MMSE) [23].

There were no differences between the three groupsin any of the Brief Symptom Inventory subscales fordepression and anxiety of the PEQOL (Table 4) and theLEIPAD depression and anxiety scales (Table 3).Comparison of the mean scores obtained in theMMSE [23] showed that they differed significantly fromgroup to group, even after covariance for educationallevel, with a trend inversely proportional to increasingage (Table 4).

The LEIPAD cognitive function scale is relativelycoherent with the mean MMSE scores, which areinversely proportional to increase in age. The threegroups differ and the centenarians appear to be awareof greater limitations in their function (Table 4).However, the administration of the MMSE revealedthat some items inappropriately influence the finaloverall score, since physical impairment (sight deficitsor arthritis preventing the subject from using a pen)makes it practically impossible for subjects to completethe final part of the questionnaire, requiring subjects todo a reading test, complete an order, write a sentenceand copy a drawing. Consequently, the maximumscore subjects can achieve, even if they are lucid andoriented but suffer from physical impairment, is 22/30.On the basis of this rationale, we have admitted to ourstudy centenarians with a score of between 8 and 27out of 30, where they are able to answer questions putto them, with a relation present to confirm the validityof the answers.

The total score for the items relating to PEQOL sleeppatterns showed that greater problems were experiencedin the intermediate group, who reported moresleep disorders than those aged 75-85 years and thoseaged 100 years or older (Table 4). The same findingcannot be compared with LEIPAD, as the scales in thisquestionnaire do not include specific questions on thisaspect.

The three groups appeared to differ significantly inSurtees' [24] social support scale included in thePEQOL, reporting scores between 4 and 7, the lowestof which (indicating that the subject perceived bettersocial support) was in centenarians and the 86-99-year-old group (Table 4). On the LEIPAD socialfunctions scale, the oldest subjects reported greatest210

Recreational activities were not maintained by thecentenarians, with the exception of four cases. Hencethey differ significantly from the components of theyounger age groups, who reported continuing suchactivities, albeit to a diminished extent, even afterANCOVA for schooling (Table 4). The LEIPAD lifesatisfaction scale includes a question on hobbies andrecreational activities. Similar findings emerged forthis item to the PEQOL one on recreational activities(Table 3). Moreover, on the LEIPAD life satisfactionscale an interesting difference emerges between thethree age groups: the mean scores are inverselyproportional to increase in age, suggesting thatsubjects who report less satisfaction belong to theyoungest age group (75-85 years of age). Thedifference appears to be statistically significant, andeven after ANCOVA for educational level the resultsremained unchanged (Table 3).Scores on the scale of economic status differedsignificantly from group to group: the subjects in all theage groups reported scores indicating overall satisfactionwith their financial circumstances, but oldersubjects and centenarians generally indicated beingmore satisfied than the younger age groups. ANCOVAfor educational level did not modify these findings(Table 4). The same result was found for the item inLEIPAD on satisfaction with financial circumstances,even after ANCOVA for schooling (Table 3).We investigated the subjects' interest in sex. Themean scores obtained by the three groups differedsignificantly (Table 4): while the subjects in the twolower age groups reported some interest, albeitdiminished in the case of those aged 86-99 years,every centenarian affirmed that they had lost allinterest in sex. ANCOVA for educational level did notmodify these findings, showing that this variable hadno influence on the result (Table 4). The same resultwas found in relation to the LEIPAD sexual functioningscale, even after ANCOVA for schooling (Table 3).Compared with the other two groups, the centenariansreported finding greater comfort from their faithand that their interest in religion had increased over theprevious year. The result was confirmed even afterremoval of the age and schooling variables by ANCOVA(Table 4). Similar result for the religious faith of thecentenarians was found on the LEIPAD religiousnessscale, even after ANCOVA (Table 3).

Discussion

People who live to 100 or older represent a selectgroup, considering that only one person in 7000-10000 reaches this age [25]. The limited sample of ourstudy does not permit generalized conclusions,although we incorporated the entire population ofthe town of Padua, the municipality of Pordenone andsix other municipalities in the Veneto region.Our data confirm Lehr's finding that there is greatvariability among extremely old individuals [15], withvarying levels of functional activity, cognitive activity211 M. Dello Buono et al.and memory. On MMSE scores, the degree of impairmentin centenarians compared with the lower agegroups confirms data on the increased prevalence ofdementia with advancing age [26, 27]. The centenariansin our study were able to answer the questionsput to them but had difficulties in performing theMMSE items requiring ability to read or write.Consequently, these items have been omitted fromthe most recent brief version of the questionnaire.Furthermore, centenarians' answers were comparedwith the opinion of a relative or the principal caregiver,who was also present during the test, both to help theinterviewee feel more secure and reassured and toconfirm the responses given or report otherwise.Individuals who reach great age depend almostentirely upon other people. Only one person weinterviewed was still able to live alone and was selfsufficientin most ADL. The mean number of functions(ADL and IADL) lost by these subjects is higher than the number lost by the less elderly; moreover, the scores ofthe latter indicate a trend which is directly proportionalto increase in age. Despite reporting poorerfunctional ability, the centenarians complained less ofpain and discomfort than their younger, functionallyless impaired counterparts. This suggests greateradaptation to the inevitable loss of functioning whichgradually impedes agility with advancing age. Suchadaptability might be an inborn characteristic of thosewho succeed in living very long lives, insofar as theyprogressively adjust their lifestyles and accept theircondition as the physiological norm. Furthermore,these very old people tend to complain less abouttheir living conditions. On the LEIPAD life satisfactionscale, they score higher than the less elderly groups.This supports the hypothesis of the role played byprogressive adjustment and positive attitude to life[2, 28].It transpires that the most well-preserved people arethose who remain intellectually stimulated, those whostill maintain satisfactory social relationships and, inparticular, can count on the help of the family or othercaregivers, and those who have spent years working incrafts requiring creative skills or who have kept theirinterests alive. These findings corroborate the results ofother Italian studies [2] and international researchwork [29-31].Most subjects reported poor eyesight and hearing,which may be one of the reasons why only a few ofthem still keep up recreational activities. Somecentenarians complain of motor deficits and urinaryincontinence. Despite this, few subjects presentedsymptoms of depression (three subjects) or anxiety(four subjects) on the Brief Symptom Inventory scale,in addition to reporting fewer sleep problems thantheir younger counterparts.Very old people attach importance to religious faith[32]: the centenarians interviewed found greatersolace in faith than the less elderly groups.Generally speaking, despite their precarious equilibrium,the old people tested by us had adapted to theircircumstances. They were often aided by their familiesor by people in the institutions where they lived.Predictors of long life include: continuing to play arole in society, keeping in good physical shape, takingpreventive measures against serious disease, lookingon the bright side of life, being intellectually stimulated,believing that happiness can be achieved, havingfinancial security, having a good life expectation andmaintaining satisfactory social relationships [33, 34].Increasing our sample size might allow us to verifypossible adaptive mechanisms highlighted by thisstudy. Longitudinal studies will permit assessment ofthe adaptations made by extremely old people whichmight be useful in revealing the secrets of long life.

Key points

• When 38 centenarians were compared with groupsof subjects aged 75-85 and 86-99 years using twoquestionnaires for assessing quality of life in elderlypeople, the centenarians were less inclined tocomplain about their physical condition and,despite greater functional disability, were no moresubject to depression or anxiety than the youngergroups.

• The centenarians have well-preserved cognitivefunction and a good level of social support, findsolace in religious faith and are satisfied with theirfinancial situation. They are no longer interested insex (in contrast to those aged 86-99 years) andrarely practice recreational activities, but reportgreater satisfaction with life than less elderlysubjects.

• Those who reach 100 years of age adapt tocircumstances and have a positive attitude to lifeand good social and family relations.

2. Cognitive symptoms: Mini Mental State Examination (Folstein et al., 1975)3. Psychological symptoms: Brief Symptom Inventory (Derogatis and Melisaratos, 1983)4. Instrumental activities of daily living: Index of Instrumental Activities of Daily Living (Lawton and Brody, 1969)5. Activities of daily living: Index of Activities of Daily Living (Katz, 1970)6. Sleep disordersHow many days have you had difficulty in sleeping during the last month?How many days during the last month have you woken up during the night at least twice?How many days during the last month have you woken up too early and had difficulty going back to sleep?How many days during the last month have you woken up still tired, even though you had slept as usual?How many times a week do you have difficulty keeping awake and need to take a nap?Score: 0, never; 1, 1-3; 2, 4-7; 3, 8-14; 4, 15-21; 5, 22-31.7. Social support: Social Support Index (Surtees, 1980)8. ReligiousnessIs religious faith a comfort to you in your everyday life?Has your interest in religion increased over the last year?Scoring; 0, not at all; 1, at little; 2, somewhat; 3, quite a lot, 4, much.9. Recreational activitiesOver the last year how have your recreational activities been? How does this compare with before?Include activities from simply playing cards to more complex ways of organizing leisure time. Exclude watching television

AbsentPresentScoring: 0, decreased compared with before; 1, the same as before; 2, increased compared with before.10. Economic statusDo you feel that you have sufficient food and clothing for your own personal use?Are your living conditions adequate, even in the winter?Do you feel you could cope with an emergency situation with your present financial resources?Scoring: 0, not at all; 1, at little; 2, somewhat; 3, quite a lot; 4, much.11. Sexuality

Over the last year (or since the last assessment) what has your interest in sex been? How does this compare with before?AbsentPresentScoring: 0, decreased compared with before; 1, the same as before; 2, increased compared with before.214

Quality of life and longevity

Appendix 2. LEI PADThe instrument should be administered following the order of the figures indicated for each itemCore instrument (31 items)Physical functioning scale (theoretical score: 0-15)1. How would you rate your overall physical health?6. Do you have sleep problems?7. Do you get tired, without energy?9- Are you able to accomplish your usual tasks, either at home, at work or elsewhere?12. How much do your physical health problems (if any) stand in the way of doing the things you want to do?Self-care scale (theoretical score: 0-18)2. Are you able to get up and down the stairs without help?3- Are you able to dress by yourself?4. Are you able to eat by yourself?5. Are you able to bathe or take a shower by yourself?10. Can you shop by yourself?11. Can you travel by public transport?Depression and anxiety scale (theoretical score: 0-12)17. Taking everything into consideration, how anxious do you feel?18. How much do your feelings of anxiety (if any) stand in the way of doing the things you want to do?19. Taking everything into consideration, how depressed (blue) do you feel?20. How much do your depressed feelings (if any) stand in the way of you doing the things you want to do?Cognitive functioning scale (theoretical score: 0-15)8. Do you have difficulties in concentrating?13- How often does it happen that you are not able to think clearly or that you are confused?14. How much do your problems with thinking (if any) stand in the way of you doing the things you want todo?15. How good is your memory?16. How much do your memory problems (if any) stand in the way of you doing the things you want to do?Social functioning scale (theoretical score: 0-9)21. How satisfied are you with your social ties or relationships?22. Do you feel emotionally satisfied in your relationships with other people?23. Is there someone to talk about personal affairs when you want to?Sexual functioning scale (theoretical score: 0-6)24. Are you interested in sex?25. How often do you have sexual contact?Life satisfaction scale (theoretical score: 0-18)26. How satisfied are you with your ability to manage your hobbies or recreational activities?27. How satisfied are you with your financial situation?28. Do you feel that you cannot afford the standard of living you would need?29. How satisfied are you in general with your life at present when compared with the past?30. Taking everything into consideration, how do you expect things will go in the future?31. How much do your expectations of the future stand in the way of you doing or initiating the things you wantto do?Moderators (18 items)The perceived personality disorder scale (theoretical score: 0-6)39. How often do you feel that most people cannot be trusted?Do you agree with any of the following statements?45. "Over the past several years, I have often been troubled by the difficulties I have in dealing with others.'46. "Over the past several years, I have been bothered by the kind of person I am."215M. Dello Buono et a\.41. "Over the past several years, the way I have behaved has often got me into trouble, either at work, at home orelsewhere."48. "Over the past several years, other people have often seemed bothered by the things I do or say."49. "I haven't got as far as I'd like to because of the kind of person I am."The anger scale (theoretical score: 0-4)Do you agree with any of the folio-wing statements?32. "I feel easily annoyed or irritated."33- "I have temper outbursts that I cannot control."34. "I get into arguments with others."35. "I tend to be resentful."The social desirability scale (theoretical score: 0-3)Do you agree with any of the following statements?42. "I am always ready to go out of my way to help someone else."43- "I like to gossip at times."44. "There have been times when I was quite jealous of the good fortune of others."Self esteem scale (theoretical score: 0-3)36. Taking everything into consideration, do you feel inferior to other people?37. How often do you avoid things (refrain from doing things) because you feel inferior?38. "I tend to have a negative opinion of myself": do you agree with this statement?Trust in God scale (theoretical score: 0-2)40. Do you believe in God or some superior being?41. Do you find comfort or support in such a belief?216